Shital N. Parikh (ed.)The Pediatric Anterior Cruciate Ligamenthttps://doi.org/10.1007/978-3-319-64771-5_2

2. History of Ligament Injuries in Children

Shital N. Parikh¹

(1)

Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

Shital N. Parikh

Keywords

HistoryLigament injuryACL tearACL repairArthroscopy

As Carl Stanitski quoted in the first chapter, “There is dead medical literature and there is live one. The dead is not all ancient, and the live is not all modern.” A review of the literature would help to appreciate the efforts that have led to the steady advancement in the field of pediatric sports medicine, to learn from the mistakes made in the past, and to potentially prevent complications in the future. It is truly enlightening to read the experiences, success stories, frustrations, and motivation of great minds that have helped to shape the exciting field of pediatric sports medicine. On digging a little deep into the history, one would quickly learn that the medical literature is very much “alive.” Some of the current techniques and “novel” ideas are, after all, not that novel. They are refinements of preexisting (and often abandoned or forgotten) ideas. One can call it “reinventing the wheel” but in a positive sense. The following chapter summarizes the history of ligament injuries in children prior to 1990, with focus on ACL tears. With increased recognition of true ligament injuries in children, knee arthroscopy gained increased popularity as a diagnostic tool. Currently, MRI is the standard diagnostic modality for suspected knee injuries; prior to 1990, there have been no reports on the use of MRI for evaluation of knee injuries in children.

Ligament Injuries in Children

Professor Ivar Palmer (1897–1985) of Sweden was one of the greatest knee ligament surgeons to have lived [1]. In 1938, he published a book On the Injuries to the Ligaments of the Knee Joint which offered a glimpse of his in-depth knowledge related to ligament injuries around the knee [2]. The book provides detailed description of 57 patients with ligament injuries. Two of these were in children: a 13-year-old boy with femoral avulsion of posterior cruciate ligament and a 15-year-old boy with tibial avulsion of the anterior cruciate ligament (ACL). Compared to bony avulsion ligament injuries, mid-substance injuries or tears of the ligaments of the knee in children had been rarely reported prior to this. These ligament injuries are considered to be uncommon as the adjoining physis and bone were weaker than the ligaments and hence failed first [3]. With the increasing use of diagnostic arthroscopy in the 1970s (and with the advent of MRI later), ligament injuries in children became increasingly recognized [4, 5]. In 1979, Bradley et al. reported the first series of knee ligament injuries in six children less than 12 years of age; in the same year, Clanton et al. reported their series of nine children less than 14 years of age with knee ligament injuries [6, 7]. Clanton et al. reviewed 1749 cases of knee ligament injuries reported prior to 1979 and were able to find 9 cases of injuries in those less than 14 years of age [5, 7–14]. However, thorough review of the older literature related to knee ligament injuries revealed the following shortcomings:

1.

The previous published reports on knee ligament injuries combined adults and children, without detailed description of cases. O’Donaghue reported on 82 patients who underwent surgical treatment for the “unhappy triad” of MCL, medial meniscus, and ACL injury, over a span of 15 years (1938–1953) [8]. The series included a 6-year-old girl, but no additional description of the case was provided. Since 85% of patients in the series had medial-sided injury (MCL or medial meniscus) and 75% of patients had ACL tears, one can only speculate the type of injury in the 6-year-old.
2.

Several series of knee dislocation and knee fractures reported multiple ligamentous injuries in patients through a wide age range, without detailed description of pediatric patients or their injury patterns. Shields et al. reported on 24 patients with knee dislocation with their ages ranging from 11 to 60 years [9]. Shelton et al. reported on occult knee ligament ruptures associated with fractures in 34 patients, with the youngest patient being 12 years old [10]. The youngest patient in the series of 43 cases of knee dislocation reported by Taylor et al. was 8 years old [11]. These reports included cases of multiple ligamentous injuries in children, but lacked further details.
3.

The earlier reports on knee ligament injuries include ligament avulsion fractures as well, making it difficult to delineate intra-substance ligament tears as a separate group. Abbott et al. reported on 26 patients with ligament injuries [15]. The youngest patient in their series (a 12-year-old boy) had sustained a tibial spine avulsion fracture. It had long been known that children sustain ligament avulsion fractures more commonly than ligament tears [16]. However, these avulsion injuries are frequently grouped and reported together with interstitial ligament injuries in the older literature.
4.

Till the 1990s, ligament injury series in skeletally immature patients reported the chronologic age of the patients, rather than skeletal age or Tanner stage, which is more relevant [17, 18]. Bergstorm et al. reported on knee arthroscopic findings in 71 children less than 16 years of age [19]. Of these, majority (51 of 71 children) were 14 and 15 years old and likely skeletally mature. Thus, defining skeletal immaturity based on chronologic age and reporting it as pediatric injuries have diluted the older literature (and even recent ones) as to the true incidence of these injuries in patients with open physis.
5.

Injuries in children have been thought to heal faster and more reliably than in adults. Surgery was rarely performed for ligamentous injuries in children. Most were treated conservatively. Since the diagnosis of a ligament tear could only be confirmed at the time of surgery (in absence of MRI), there was paucity of reports on injury patterns in children [6].

Mid-Substance ACL Tears in Children

The timeline of pediatric mid-substance ACL tears suffers from some of the same shortcomings as ligament injuries in children in general, as mentioned above. Several series of knee arthroscopy in children have been published; the ones without documented ACL tear have been excluded from this chapter.

In 1978, Youmans reported on 32 cases of isolated ACL tear with their ages ranging from 13 to 45 years [13]. Average age of the cohort was 21 years, eight patients were less than 16 years of age, but the number of skeletally immature patients was not reported. Of 32 cases, 21 had surgical treatment which included pes anserinus transfer with or without iliotibial band transfer, and 11 were treated nonsurgically. Twelve of 32 patients had poor results with increased instability or new meniscus tears.

Nakajima et al. reported on 118 cases of ACL tears, diagnosed by arthroscopy or arthrotomy between 1973 and 1978 [20]. Their ages ranged from 10 to 34 years, with most patients being athletes. Eighty-one percent of patients had associated meniscal tears. The authors describe the N (Nakajima) jolt test which is akin to the pivot shift test routinely used today for clinical diagnosis. Thirty-two cases were treated with iliotibial tract transfer, but specific details related to skeletal immaturity and treatment were lacking in their report.

In 1979, Bradley et al. reported on six children (6–11 years of age) with medial collateral ligament (MCL) tears who were surgically treated by primary repair [6]. Two patients had concomitant ACL tibial spine avulsion fractures, and a 13-year-old had a concomitant mid-substance ACL tear. The ACL tear was primarily repaired using sutures with a fair outcome; despite some rotatory instability on clinical examination, patient was able to hike and ski without much symptoms.

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